By Kashyap Patel
Rheumatoid arthritis (RA) is a systemic inflammatory disease that is associated with progressive debilitation and early death. From a young age, I was exposed to the horrors that this disorder can unleash on a person’s life. My maternal grandmother has severe RA and I have seen her increasingly suffer over the last two decades. She often finds it incredibly difficult to perform activities of daily living (moving around, preparing meals and dressing) due to the pain and stiffness. This experience instilled in me a sense of curiosity about the disease and how I can help her alleviate her symptoms.
In my second year, I was lucky enough to be placed in a biochemistry inquiry course that focused on the efficacy of sulfasalazine (an anti-rheumatic drug) in treating RA. This course reignited my passion for exploring this complex disease and its vast variety of treatment options. In my third year, I had the opportunity to do a research project on current and novel pain management strategies for RA patients. This project allowed me to expand my understanding of RA and how it can impact those suffering from it.
I learned that RA does not only affect joints and cartilage. Its disease burden also involves dire cardiovascular, pulmonary and psychological implications (1). In Canada, there are 272,000 people living with RA and its prevalence is expected to increase over the next 30 years (2). This warranted a thorough investigation into how healthcare providers can improve the quality of life for RA patients.
A study with over a thousand RA patients indicated that 70% of the patients want to see improvements in their pain management (3). Pain is a major concern amongst RA patients and thus, research into effective pain management strategies should be a crucial part of rheumatology. Despite this, it is rarely discussed in clinical guidelines that outline treatment strategies. The Canadian Rheumatology Association and the American College of Rheumatology have very similar approaches to treating RA (4,5). They recommend the use of disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate (MTX), sulfasalazine and hydroxychloroquine. They recommend that DMARDs should be prescribed to RA patients as soon as possible and as the first pharmacologic therapy (4,5). DMARDs usually do not help with pain directly because they target immune pathways that eventually decrease the severity of the disease.
Pain is a complex symptom that can be influenced by the disease, environmental and psychosocial factors (6). The American College of Rheumatology Pain Management Task Force found that rheumatologists do not identify themselves as “pain physicians” because they treat a very specific form of pain: musculoskeletal acute/chronic non-malignant pain. Traditionally, rheumatologists have primarily treated nociceptive pain in RA patients with the use of non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids (6). However, non-pharmacological interventions such as cognitive behavioural therapy (CBT) are also becoming more popular as the biopsychosocial model of the disease becomes more accepted in medical circles. Approaches like music therapy and CBT allows patients to address the psychological and social aspects of pain which are often overlooked (7-11).
Furthermore, the WHO has published their world-renowned “pain ladder” which ranges from using non-opioids such as aspirin for mild pain to using opioids such as codeine and morphine for moderate to severe pain (12). This strategy was initially developed for cancer pain, but the WHO claims that this plan can be used for non-malignant pain as well. It recommends a “by the clock” administration routine to gain “freedom from pain” (12). Clearly, these are vague guidelines that are not supported by high-quality evidence. Pain manifests itself differently depending on the disease and a broad guideline for managing pain in non-malignant cases is not feasible. Not only are these guidelines vague, but they also fail to recommend non-pharmacological approaches (such as CBT and music therapy). The WHO also does not recognize that pain can be influenced by environmental and psychosocial factors. Therefore, the WHO provides an oversimplified perspective on pain management that is not useful for RA patients.
The Royal College of Physicians and Surgeons of Canada has training objectives for the subspecialty of rheumatology that a candidate must meet to be certified to practice rheumatology in Canada. These competencies are categorized under the facets outlined by the CanMEDS roles (13). These roles are a medical expert, communicator, collaborator, leader, health advocate, professional and scholar. Training programs across Canada must comply with this protocol when instructing rheumatology residents.
The residency training program for rheumatology includes learning about a variety of inflammatory diseases. However, there is a surprising lack of focus on pain management throughout this residency training program (13). Rheumatologists often have to rely on referring their patients to pain specialists to address RA pain and to develop a pain management strategy. The objectives of training for pain specialists cover both pharmacological and non-pharmacological pain treatments (14). The issue with that system is that pain clinics have long wait times in Canada and RA patients often wait months before getting a consultation. A survey study indicated that only 37% of the patients attending Canadian pain clinics thought that their wait time was appropriate (15).
Rheumatologists should also be trained to identify and prescribe pain management strategies for their patients. Their practice involves treating a population in which pain is a prevalent symptom. This lack of coordination of care between rheumatologists and pain specialists can be addressed by teaching rheumatology residents some RA-specific pain management strategies. These would include evidence-based training that encourages rheumatologists to take a multi-disciplinary approach and consider the interests of the patient. For the patients, this would mean less waiting in pain and an increase in their quality of life. Therefore, it is important to develop a training program based on the evidence available.
I realized that these shortcomings of the Canadian healthcare system have some dire implications for me. RA is caused by environmental and genetic factors which means that I have a greater chance of developing it than those who do not have a family history of this disease. This is an opportunity for policymakers and educators to address this issue for the betterment of hundreds of thousands of Canadians.